完全清醒无血无止血带局部麻醉技术联合闭合复位经皮克氏针顺行固定术治疗第四、五掌骨颈骨折

Percutaneous Kirschner wire antegrade fixation combined with wide-awake technique to administrate fourth and fifth metacarpal neck fractures

目的探讨完全清醒无血无止血带局部麻醉(wide-awake)技术联合闭合复位经皮克氏针顺行交叉固定治疗第四、五掌骨颈骨折的临床应用价值。方法回顾性研究。纳入徐州市仁慈医院2017年1月—2019年12月第四和/或第五掌骨颈闭合性骨折患者19例,均为男性,年龄11~45岁、平均20.8岁。第五掌骨颈骨折14例,第四掌骨颈骨折3例,第四、五掌骨颈骨折2例;横行骨折17例,粉碎性骨折2例(其中1例骨折累及掌指关节);骨骺板未闭4例。19例均采用wide-awake技术联合闭合复位经皮克氏针顺行交叉内固定手术治疗。观察指标:(1)手术时间;(2)手术相关并发症;(3)术后随访观察患侧第四、五掌骨颈掌屈角度,骨折愈合情况,骨骺板闭合情况,掌指、近指间及远指间关节的主动活动度和抓握力;(4)末次随访时,按指关节总的主动活动度(TAM)系统方法以及肩臂手功能障碍评分量表(Quick-DASH)评定疗效。结果本组19例患者均顺利完成手术,手术时间22~46 min、平均31.8 min。术后18例患者获随访6~12个月,1例失访。所有患者骨折均愈合,愈合时间为8~12周、平均9.3周,无一例并发感染、局部疼痛、骨折再次移位、掌骨缺血性坏死或掌指关节退行性征象以及断针或退针等并发症,其中骨骺板未闭4例均未见骨骺早闭。末次随访时患者第四、五掌骨颈背侧成角角度从术前的45.6°±14.6°降至11.0°±1.7°,差异有统计学意义(t=10.55,P<0.001);患者的掌指及近、远指间关节主动活动度良好,握力良好,无指体旋转畸形;按指关节TAM系统方法及Quick-DASH评价,18例患者疗效均为优。结论采用wide-awake技术联合闭合复位经皮克氏针顺行固定治疗第四、五掌骨颈骨折,固定可靠,对关节无影响,愈合时间短,疗效满意,是较好的治疗选择。

Objective To investigate the application and clinical effect of wide-awake technique combined with closed reduction and anterograde cross fixation with percutaneous Kirschner wire to treat fourth and fifth metacarpal neck fractures.Methods A total of 19 male patients with closed fractures of the fourth and/or fifth metacarpal neck in Xuzhou Benevolent Hospital from January 2017 to December 2019 were included in the retrospective analysis.The patients were aged 11 to 45 years,with an average of 20.8 years.A total of 14 patients had a fifth metacarpal neck fracture,3 patients had a fourth metacarpal neck fracture,and 2 patients had a fourth and fifth metacarpal neck fracture.A total of 17 patients had transverse fractures,and 2 patients had comminuted fractures.Four patients had a metacarpal neck fracture with patent epiphyseal plate.All 19 patients were treated via wide-awake technique combined with closed reduction and anterograde cross internal fixation with Pico Kirschner wire.The outcome measures were as follows:(1)operation time;(2)surgical complications;(3)postoperative follow-up observation of the affected side of the fourth and fifth metacarpal neck and metacarpal flexion angle,fracture healing,epiphyseal plate closure,metacarpal phalangeal,proximal interphalangeal,and distal interphalangeal joint active range of motion and grip strength;(4)At the last follow-up,the efficacy was evaluated according to the total active motion(TAM)method and the scale of quick disabilities of the arm,shoulder,and hand(Quick-DASH)method.Results All the 19 patients in this group received surgery successfully.The operation time was 22-46 min,with an average of 31.8 min.All fractures were healed without redisplacement.The healing time was 8-12 weeks(average 9.3 weeks).Eighteen patients were followed up for 6-12 months.None of them had complications,including infection,local pain,redisplacement of fracture,metacarpal avascular necrosis or degeneration of metacarpophalangeal joint,or broken or withdrawn needle,and no premature epiphyseal closure was found in four cases of patent epiphyseal plate.The fourth and fifth metacarpal neck dorsal angulation decreased from 45.6°±14.6°before operation to 11.0°±1.7°after operation,and the difference was statistically significant(t=10.55,P<0.001).The patients'metacarpophalangeal,proximal interphalangeal,and distal interphalangeal joints had good active movement and hand shape without rotation deformity of the fingers.According to the evaluation of TAM and Quick-DASH,the efficacy of the 18 patients was excellent,and the rate of excellent and good outcome was 100%.Conclusions Wide-awake technique combined with closed reduction and anterograde percutaneous Kirschner wire fixation is used to treat fourth and fifth metacarpal neck fractures.The fixation is reliable,without effect on the joints,which has a short healing time,and satisfactory curative effect.It is an excellent treatment choice.